THFWS and TTM’s: A Few Observations about Healthcare Insurance in America

THFWS and TTM’s: A Few Observations about Healthcare Insurance in America

Insurance is one of the most insidious fear-based institutions enslaving America today. The power with which insurance companies hold all of us is evidenced by the fact that insurance companies own many of the industries of America.

For more than fifty years it has become increasingly apparent that an axis of evil represented by attorneys, insurance companies, and pharmaceutical manufacturers has held us in a crossfire from which there appears to be no escape.

Seeing opportunity amongst the glut of avarice and profiteering, healthcare insurance administrative companies have now established and ingratiated themselves so insidiously that it would appear that few people have even noticed their presence.

A Remora is a small fish that attaches itself to the belly of a shark. It is considered to be a symbiotic relationship because the shark benefits from the cleaning that the Remora provides and the Remora benefits from the free food, transportation, and the protection.

Healthcare insurance administrative companies began much like the Remora, as they were initially relatively small and benign. They did not provide the insurance; they simply managed the plan for the companies. It was symbiosis, and both parties benefitted, at no great threat to the public.

This is where the analogy falls apart, however. In recent years healthcare insurance administrative companies now steer the shark, tell it when and whom to eat, and if sufficiently provoked will represent a serious and grave threat in and of themselves. Their appetites are also now as rapacious as that of the shark itself.

At least one of them was allegedly spawned from the belly of a pharmaceutical manufacturer itself, and although the courts eventually ruled that they had to divest themselves of each other due to the potential monopoly they represented, what grew out of that entity may prove far more dangerous. Congress approved it, and no one seems to have even noticed.

Family coverage for most healthcare insurance plans costs between $300-$400 dollars per month, depending upon your insurance benefits, if you have a job that provides group coverage.

Most plans have deductibles ranging from between $1600 to $3000 per family. That amounts to almost eight thousand dollars a year just to actually receive any benefits from your healthcare insurance.

After the deductible is met, most plans pay 80 percent of allowed claims for network providers and allowed medications, excluding chiropractic and acupuncture services; (if allowed at all; almost none of them pay more than 50 percent.) Non-network providers similarly are almost never paid at a rate greater than 50 percent.

These so-called cost-sharing measures do not so much represent the necessity of providing the monies the insurance company needs to defray costs as it represents deterrents designed to discourage members from using their insurance, seeing their doctors, going to the hospital, or even taking medications at all.

Some plans provide for pre-tax flexible spending accounts, healthcare spending benefits plans or other provisions to help hedge against the deductibles and other costs. If all goes well, good for you.

If not, you may find your account frozen with thousands of dollars unavailable until you send them a check or money order for as little as ten cents’ expenses that they have decided to contest for reasons that defy description. If it is not handled in a timely manner, you may even loose the remaining frozen assets allocated for that year.

Network vs. non-network as well as preferred vs. non-preferred are terms fraught with suspicious definitions that smack of collusion and impropriety to those of us who might be inclined in our “ignorance” to question the criteria for such labels, regarding them in the same manner as one might view competition for turf by rival gangs.

Physicians who charge more than the “usual and customary fees” have to be paid by the insured “out of pocket”. Those “usual and customary” fees are so notoriously low that almost no physician falls within the criteria, leaving one to wonder how those fees can be considered “usual and customary”.

Walk-in clinics (aka “Doc-in-a-Box”) usually charge the uninsured about the same amount of money as what the insured pay in co-payments. I do not personally recommend their services, based on my own experiences; it is just mentioned as a point of reference.

Allowed vs. non-covered medications, as well as terms such as preferred vs. non-preferred medications either eliminate certain types of therapy completely, or make them prohibitively expensive.

Prior Authorization is often required for many medications to be covered, based on a process called coverage review which requires the physician to take the time to make a phone call (thirty-minute wait times are not uncommon, btw) to plead your case in order to have the claim allowed, only to find out that once it is considered “authorized” you may still be required to pay one hundred percent of the total cost of the medication as if you had no insurance at all.

Just to add to the confusion, prior authorization is a term that can be used to describe completely different processes and procedures required by the insurance administrators. Imagine if a doctor used the same term to describe a hemorrhoidectomy, brain surgery, and breast augmentation.

This newspeak of medical healthcare insurance has created a state of confusion similar to that which was evidenced by the multiple meanings of “Aladeen” in Sacha Baron Cohens’ The Dictator.

It is no accident. Confusion creates delays in pay-outs, and time is money when the insurance administrators earn interest by virtue of the delays.

All insurance companies rely on a paradigm of “attrition of claims based on successive denials”. In other words, if a calculated percentage of the claimants will give up after each stage that their claim is denied, escalated, reviewed, re-submitted, processed, denied again, adjudicated, litigated, etc. eventually only the most die-hard petitioners will ever realize any satisfaction at all, and for even for those that do, your delay is their money.

This not only reduces the amount of money that the insurance companies pay, but the interest generated on the money unpaid on delayed claims makes even more money. These denials are regarded as “damage control” and have consistently made incremental erosions into what is considered a legal basis for denials of coverage.

Another feature of pharmaceutical healthcare insurance is to bamboozle the insured with a barrage of initializations that stand for premises that in and of themselves are arbitrary attempts to make the insured believe that they have no choice. In some cases, that is an actual point in fact.

Some plans use a term to disguise your inability to refill your prescription more than a pre-specified number of times at your local retail pharmacy. There is an initialization for it.

Some plans require you to call the program administrator (not the provider) to register your choice to stay with your local pharmacy. If you don’t, you pay full retail price. Others require that if you don’t make a choice by a certain date, you lose your opportunity to make any choice at all.

Whatever happened to being able to make your own choices without having to beg for permission?

January 1st of 2014 ushered in the proclamation of a list of forty-eight of the most commonly prescribed medications that were suddenly denied and no longer covered.

Almost all of these medications had previously been approved for coverage for several years and were part of well-established treatment modalities and accepted courses of action by the medical community. No good reason has been forthcoming as to the rationale for this capricious edict, as issued by healthcare insurance administrators.

Since 2012 almost all competition between healthcare insurance administrators has been eliminated.

All pharmaceutical manufacturers keep entire law firms on retainer to challenge the seventeen-year limit imposed on exclusive rights to their patents as brand-name medications, claiming excessive costs for research and development, including the costs of their failures to produce drugs that the FDA will eventually approve after several years of clinical trials, including marketing the medication in third-world countries and “voluntary” trials in prisons and on people who are willing to be paid to be used as test subjects.

Additional extensions of the seventeen-years of exclusive rights may be allowed for another four or more years.

No other type of patent is routinely granted these kinds of exclusivity.

Keep in mind that few industries other than oil and insurance realize the kind of windfall profits that are routinely made by pharmaceutical manufacturers.

Once generic licenses are issued to manufacture a medication, it is not unusual for the original brand-name manufacturer to withhold what is considered “proprietary” information (i.e. secrets) about how to manufacture that medication so as to make it a true generic equivalent of the original.

Once the FDA approves the generic medication, the insurance companies (by way of insurance administrators) will make it increasingly difficult (expensive) to purchase the original brand name medication, regardless of how many patients report decreased effectiveness, allergic reactions and undesirable side effects.

Although in theory, the FDA requires adherence to certain quality standards for those generic medications if they were manufactured in the US, this country is being flooded with a plethora of “Dr. Bombay’s Bathtub Batch” manufacturers from overseas third-world countries where safety, sanitation, and other concerns are much lower than in the United States. These medications are also allegedly subject to the same standards, but the actual products themselves seem to indicate otherwise.

How some of these medications ever pass the allegedly rigorous standards we have been taught to believe we are guaranteed in this country defies imagination.

Many of these medications are so poorly produced and pressed that they disintegrate before they are received by the patients, especially if they are then “mail-order” shipped to their victim/recipients.

Some of those medications taste and/or smell so bad as to be almost impossible to ingest, despite the fact that the original brand-name medication did not possess those same undesirable characteristics.

I was recently shipped a generic medication that I had taken for more than two years that previously had no discernable odor at all and had a slight coating to it that made it easy to swallow. The new generic version of this medication had a rough finish, was poorly pressed and possessed an odor of what smelled like plasticizers that reminded me of cat urine on a small children’s toy. I now no longer take the medication. They won.

Nausea, vomiting, dysphagia, dyspepsia, diarrhea, horrific flatulence, possibly accompanied by “unexpected oily discharges”, rashes and even anaphylactic reactions are among the laundry list of complaints registered by users of these generic medications allegedly declared safe, assuming that the medication works at all, or doesn’t need to be increased by two hundred percent to achieve desired or even consistent results.

Even the quality and durability of the containers themselves and their labeling, (including poor print quality or legibility) has deteriorated rapidly over the last two years to the point that the pill containers themselves do not always survive mail-order shipment.

The new containers are so thin and flimsy that I could easily crush them between my thumb and forefinger. The old containers could have resisted hammer-blows, had I been so inclined, and apparently some post-office workers are….

Increasingly, insurance companies are often relying on “administrators” acting as management services to accomplish their avaricious schemes. Insurance companies are required to have their policies approved by each state’s Bureau of Management Services under the board of Financial Management of that state. In theory, this insures that the policy that the insurance company alleges to provide their policyholders matches certain state standards.

Ironically, at least one state’s office of financial management uses insurance that utilizes a healthcare insurance administrator to regulate (diminish) the claims of their employees.

If you regard the administrators of the insurance in the same light that one might view some of the private sub-contractors of the defense department or other government contractors who essentially do the dirty work that even the CIA won’t touch by providing deniability of responsibility for actions tacitly condoned, but publicly disavowed, you may get a feeling for exactly how it is that America is becoming enslaved by them.

Imagine that the administrator of your insurance also provides home delivery of your medications, if you so desire, for several years, but then with increasing regularity starts to require you to get home delivery after the second or third refill, or pay the full price of the medication.

For the first few years, it is for generics only, but eventually all “maintenance medications,” (brand name or generic) can only be filled by mail-order. Once again, it is the incremental erosions of your benefits that continue until you begin to question what benefits you have at all.

Now you no longer have control over who fills your prescriptions. Now you no longer have a choice as to which manufacturer you use, if it is generic.

Next, they sell you on automatic delivery, since they do not consider themselves responsible if you forget to order them until it is too late and you run out, so you agree to have them decide when to ship them.

The law states that once seventy-five percent of what your scheduled dosage is estimated to have been used, they can now send you another order. This also helps make sure that you don’t get your doctor to prescribe your medications so that you can break them in half, and make the supply last twice as long.

This should ensure that you get them anywhere from two and a half weeks to ten days early…in theory…although it is not uncommon for patients to receive their prescriptions so early that they have six weeks supply or more on hand when their new prescriptions arrive (unbudgeted and unexpected), while other patients report their medications are so late that they have to go to their local pharmacy to pay out of pocket to avoid doing without medications upon which their life may depend.

Whether this is the result of some kind of collusion or just plain incompetence is essentially a moot point. It does, however smack of arrogance as regards quality of services rendered.

Once you are on their auto-refill list, even though you may call them to inform them that your doctor has taken you off that prescription before the medication has even been shipped, they may nonetheless claim that it is still too late to cancel the order because it is already “in process”… (whatever the f*ck that means), which now means you are stuck paying for a ninety-day’s supply of something you are no longer taking, even though you told them so before they shipped it. No refunds…tough shit for you, even if you don’t open the container or accept delivery.

If you don’t use auto-refill and you don’t order the medications when they call you to tell you it is time to order more, they will cancel your prescription, forcing you to go back to the doctor to get it re-written.

If somebody steals the prescription from your mailbox, and you notify the postmaster and the police in a timely enough manner that even they can’t weasel their way out of acknowledging that a crime was committed (they will initially, by the way try to intimidate you by implying that the criminal is you until proven otherwise) they will still charge you for that medication and keep the money for (in theory) sixty days “to ensure that it has actually been lost or stolen before you got it” (as if it is reasonable to expect your prescriptions to take two months to reach you by mail-order).

(No matter how convenient it may seem, never, EVER agree to let them autocharge your credit or debit card.)

Then, (again, in theory) they will credit your account against future charges (maybe) if you hound them relentlessly until they do, all the while claiming that it is “in process” in the Accounts Receivable Department (somewhere), and you get no interest on the money they have extorted from you in the meantime.

If you can’t afford to pay for it twice and your account is too far overdue waiting for the credit, they will suspend your prescription delivery and even cancel your prescription.

After that, they will require your signature to deliver the medications so as to further inconvenience you for having asserted yourself. If you are not home at the time that delivery is attempted, you have to go to the post office to pick it up.

In years gone by, the members who suffered these practices would simply cancel home delivery and not pay the unfair charges or suffer such poor service or unreasonable demands.

They once had a choice, but after the healthcare providers began to realize that they could significantly cut the cost of their benefits to their employees, all the while denying responsibility for the actions of those who acted on their behalf, the popularity of requiring the members to accept this kind of shabby treatment has increasingly become the norm.

In this way, it is the healthcare insurance administrators who are responsible for effectively preventing you from receiving the benefits for which you pay so dearly.

One might be inclined to think that no right-thinking public official or healthcare provider would allow, let alone encourage this sort of action, or utilize the services of such deplorable characters, but like the character “Deepthroat” said in “All the President’s Men”: “follow the money”.

One such company paid millions in fines for illegal use of influence several years ago, and lost over two hundred million dollars in state-subsidized medical insurance contracts and still had the colossal gall to issue a statement that neither the fines or the loss of the state contract would significantly affect their profits for the year.

Protection from monopolization of industries such as the media, and the management of insurance or the vending of pharmaceuticals has become a thing of the past, a mere anecdotal reference on the timeline of the rape and pillage of the rights and civil liberties of all Americans by the rich and privileged who live above the law and have the same respect and regard for the quality of your lives as the strip mining companies had for the state of West Virginia.

We have Congress to blame for allowing this. Although it might be argued that because we voted them into office, it is somehow our fault, if you consider the fact that all the above-mentioned entities contribute heavily to both political parties, it makes no difference. The only difference between bullshit and horse shit is the smell.

America has the best government that money can buy.

Then again, maybe that’s just me speaking…just another random, unfocused rant by some alienated, disgruntled ne’er-do well.

If you think that this piece lacks specific examples, you would be right; there are plenty of examples which I have purposely withheld because I don’t have the money to defend myself against the lawsuits to which I would reasonably expect to be subject, regardless of their validity.

Civil law, like civil war is an oxymoron devoid of any connection to justice, truth, or civility. It’s all a matter of Trial by Money.

I can only hope to point you toward the truth…after that, it’s up to you to recognize these examples. They are full of terms like “Choice”, “Allowance”, “Select”, and other words whose meanings are frequently the opposite of what any normal person would infer. All of it is ripe with the “Newspeak” of George Orwell’s “1984”.

If you have never experienced any of these injustices and outrages, I am happy for you, and hope you never are forced to ever wake up to the reality of what is being done to so many others all around you. You are probably in reasonably good health and are currently well enough to not even need healthcare insurance, if you weren’t forced to live in fear. I wish you continued good fortune.

…Hey, who wants some pie?

And now, back to our regularly scheduled programming….





2 Responses to “THFWS and TTM’s: A Few Observations about Healthcare Insurance in America”

  1. LadyBlueRose's Thoughts Into Words Says:

    I bet you have one big headache
    and sore hands writing all this…
    another day in paradise and hopefully you won’t get sick..
    I think I am most annoyed with, if I can’t afford health insurance
    then how will I afford the fine for not purchasing it…
    in the gangster movies, the mob called that protection money
    hmmmm….I won’t comment any further…it gave me a headache thinking through all your words and knowing my Ibprophen keeps going up..
    glad I don’t go to doctors…I ask Gaia and She usually shows me how to take care of myself…
    Good Post….I was glad to see you …
    Take Care…You Matter…

    • I wrote it as a background piece for The Home for Wayward Souls and the Talking Monkeys, and partly to clear my head and unburden my soul…I have become privy to how that whole system works by virtue of my involvement in it…there are some very rotten things happening within the healthcare industry…for me, visualizing the mechanics of what is being done to us, instead of just accepting it helped unburden my analytical brain…but before the whole story is finished, you will see how it fits into the backstories of the novel.
      …and yes, I am paying attention…I enjoy your subtle references to those things I believe we share as common knowledge…it’s like noticing a wink from across a crowded room, or reading a story within a story.
      Sorry for the headache…I have very strong hands, but I try to use them to heal and inspire, so they don’t get sore.
      We should practice Satsang more often.

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